Contact

Links

Research & Scholarship

Current Research and Scholarly Interests

I am interested in graduate medical education -- particularly in understanding how learners learn best and how to optimize graduate medical education given recent work hours changes, increasing handoffs, increasing patient safety standards which have led to increased supervision, and limited longitudinal exposure with faculty.

A few of my studies/areas of interest include: (1) Coaching Initiative: An innovative approach to provide longitudinal assessment and feedback to residents, and help residents develop skills of lifelong learning and self-reflection. This program pairs a faculty coach with ten residents, who they follow for all three years. We are studying the impact on the amount and quality of feedback given, the residents' communication skills, and impact on faculty through faculty development. (2) Bedside IPASS Study: Improving Family-Centered Rounds to Improve Patient Safety and Communication: We are one of seven sites in this national study to evaluate the impact of a new FCR rounding structure on patient safety and communication with patients and families. (3) Shared Decision-Making: We are one of four sites on this NIH R25-funded study of shared decision-making on internal medicine and pediatrics rounds. (4) Scholarly Concentrations: We are studying the impact of scholarly concentrations on resident learners' scholarship, subsequent scholarly activity, career development.

Prior studies have included: (1) National Nighttime Curriculum Study: Measured the impact of a national nighttime curriculum on residents' perception of learning, confidence and knowledge in handling routine overnight issues. Prospective study of 89 residency programs, over 2000 learners that found a significant improvement in knowledge, confidence, and attitudes. (2) IPASS Study (National Handoff Study; we were one of nine pilot sites): Implemented an educational intervention to improve residents' knowledge and use of handoff tools. (3) Remediation: Created better tools for identifying and helping remediating learners. (4) Residents as Teachers: Measured the impact of our required senior resident rotation in teaching.

Publications

All Publications

Abstract

Research on resident workloads has focused primarily on the quantity of hours worked, rather than the content of those hours or the variability among residents. We hypothesize that there are statistically significant variations in resident workloads and better understanding of workload intensity could improve resident education.The Stanford Children's Health research database was queried for all electronic notes and orders written by pediatric residents from June 2012 to March 2014. The dataset was narrowed to ensure an accurate comparison among residents. A survey was used to determine residents' self-perceived workload intensity. Variability of total notes written and orders entered was analyzed by ?(2) test and a Monte Carlo simulation. Linear regression was used to analyze the correlation between note-writing and order-entry workload intensity.A total of 20?280 notes and 112?214 orders were written by 26 pediatric interns during 6 core rotations between June 2012 and June 2013. Both order-entry and note-writing workload intensity showed highly significant (P < .001) variability among residents. "High workload" residents, defined as the top quartile of total workload intensity, wrote 91% more orders and 19% more notes than "low workload" residents in the bottom quartile. Statistically significant correlation was observed between note-writing and order-entry workload intensity (R(2) = 0.22; P = .02). There was no significant correlation between residents' self-perceived workload intensity and their objective workload.Significant variations in workload exist among pediatric residents. This may contribute to heterogeneous educational opportunities, physician wellness, and quality of patient care.

Abstract

High-quality care for children with medical complexity (CMC) is in its infancy. Residents have the opportunity to view care for CMC with a fresh perspective that is informed by their work across diverse health care settings and significant time spent at the bedside. This study aimed to identify the challenges and potential solutions for complex care delivery and education from their perspectives.We conducted three 60-minute focus groups with a purposeful sample of residents and recent graduates at a US tertiary-care medical center. Data were transcribed verbatim, and themes were identified using an iterative approach and modified grounded theory.Sixteen participants identified 4 major challenges to caring for CMC: 1) lack of care coordination; 2) complex technology management; 3) patients' pervasive psychosocial needs; and 4) lack of effective health care provider training. Participants identified 3 solutions: 1) greater integration of primary care providers; 2) attention to psychosocial needs through shared decision making; and 3) integration of longitudinal patient relationships into provider training. We found that residents who experienced longitudinal relationships with CMC felt more efficacious and better equipped to handle challenges of caring for CMC as a result of their broader understanding of patients' priorities and of their role as providers.Residents recognize important challenges and offer thoughtful solutions to caring for CMC. Although multiple solutions exist, formal integration of longitudinal patient experiences into residency training may better prepare residents to understand patient priorities and identify when their own attitudinal changes can guide them into more efficacious roles as providers.

Abstract

Objective. To evaluate an innovative curriculum meeting new pediatric residency education guidelines, Special Care Optimization for Patients and Education (SCOPE). Methods. Residents were randomized to intervention (n = 23) or control (n = 25) groups. Intervention residents participated in SCOPE, pairing them with a child with special health care needs (CSHCN) and faculty mentor to make a home visit, complete care coordination toolkits, and participate in case discussions. The primary outcome was resident self-efficacy in nine skills in caring for CSHCN. Secondary outcomes included curriculum feasibility/acceptance, resident attitudes, and family satisfaction. Results. Response rates were ?65%. Intervention residents improved in their self-efficacy for setting patient-centered goals compared with controls (mean change on 4-point Likert-type scale, 1.36 vs 0.56, P < .05). SCOPE was feasible/acceptable, residents had improved attitudes toward CSHCN, and families reported high satisfaction. Conclusion. SCOPE may serve as a model for efforts to increase residents' self-efficacy in their care of patients with chronic disease.

Abstract

Objective. Care for children with medical complexity (CMC) relies on pediatricians who often are ill equipped, but striving to provide high quality care. We performed a needs assessment of pediatricians across diverse subspecialties at a tertiary academic US children's hospital about their continuing education needs regarding the care of CMC. Methods. Eighteen pediatricians from diverse subspecialties were asked to complete an online anonymous open-ended survey. Data were analyzed using modified grounded theory. Results. The response rate was 89% (n = 16). Of participants, 31.2% (n = 5) were general pediatricians, 18.7% (n = 3) were hospitalists, and 50% (n = 8) were pediatric subspecialists. Pediatricians recognized the need for skills in care coordination, giving bad news, working in interprofessional teams, and setting goals of care with patients. Conclusions. Practicing pediatricians need skills to improve care for CMC. Strategically incorporating basic palliative care education may fill an important training need across diverse pediatric specialties.

Abstract

The Dreyfus and Bloom frameworks can help the great clinical teacher craft questions that are learner-centric and appropriately challenging.Employing strategies to ask the right questions in the right way can further add to the effectiveness of using questions as a valuable teaching,learning, and assessment tool.

Abstract

To quantify the prevalence of social and behavioral sciences (SBS) topics during patient care and to rate team response to these topics once introduced.This cross-sectional study used five independent raters to observe 80 inpatient ward teams on internal medicine and pediatric services during attending rounds at two academic hospitals over a five-month period. Patient-level primary outcomes-prevalence of SBS topic discussions and rate of positive responses to discussions-were captured using an observational tool and summarized at the team level using hierarchical models. Teams were scored on patient- and learner-centered behaviors.Observations were made of 80 attendings, 83 residents, 75 interns, 78 medical students, and 113 allied health providers. Teams saw a median of 8.0 patients per round (collectively, 622 patients), and 97.1% had at least one SBS topic arise (mean = 5.3 topics per patient). Common topics were pain (62%), nutrition (53%), social support (52%), and resources (39%). After adjusting for team characteristics, the number of discussion topics raised varied significantly among the four services and was associated with greater patient-centeredness. When topics were raised, 38% of teams' responses were positive. Services varied with respect to learner- and patient-centeredness, with most services above average for learner-centered, and below average for patient-centered behaviors.Of 30 SBS topics tracked, some were addressed commonly and others rarely. Multivariable analyses suggest that medium-sized teams can address SBS concerns by increasing time per patient and consistently adopting patient-centered behaviors.